With the Affordable Care Act’s (ACA) increased emphasis on preventive care and community-based treatment, social workers have an opportunity to bridge the gap between physical and mental health, taking on the role of a care coordinator and working between patients and physicians.

The New York City Health and Hospitals Corporation defines care coordinators as “social workers who work with patients to create a plan that addresses mental health, physical, and social service needs.” These services can include:

Community resource planning and coordination;

Connecting patients with specialists and other healthcare providers;

Advance directives;

Helping patients understand chronic conditions;

Crisis intervention;

Counseling for emotional adjustments and lifestyle changes: and

Assistance with legal issues, transportation, or applications for financial aid.

While the benefits of community-based treatment and preventive care are already widely recognized, the ACA further incentivizes hospitals and care providers, imposing sanctions when patients come back too soon after being released, increasing the value of community-based preventive care programs. One such program is a Health Home, a free program (not a physical location) that helps patients manage the care and services that they need. In a health home, beneficiaries are paired with care coordinators who help them better understand and manage their conditions outside of the hospital setting.

Social Workers’ Role in Healthcare Reform

The ACA specifically mentions social workers as key players in implementing healthcare reform, which means they will likely have an opportunity to shape policy by advising policymakers on the following aspects of reform:

Effect and influence of social and environmental factors: Healthcare issues are much larger than the individual, and social workers will recognize how policy should best account for these factors.

Appropriate timeline and perspective: Social workers interact with individuals of all ages and think in terms of a life span, as opposed to short-term goals.

Advocacy: Social workers concern themselves with matters that extend beyond their individual clients. Social equity surrounding the access of care is a paramount concern of social work professionals, and as a result, social workers can become healthcare advocates in their communities.

Comprehensive care planning: Effective care, and thus policy, must take into account families, communities, and service providers.

Access expansion: Social workers understand that between human services, clinics, hospitals, mental health facilities, the community, and the home, there are many places where access to care is denied or not aligned with other phases of treatment.

Social work education: Medical education typically focuses on identifying and treating disease and physical illness, while social work education focuses instead on prevention, community support, and case management.

In the future, there will be more social workers bringing their unique educational background to the healthcare system. Significant post-ACA expansions to healthcare services, particularly for low-income individuals, as well as an emphasis on community-based preventive care, will likely create more career opportunities for social workers in the United States.

With more people than ever obtaining healthcare coverage, there will be a high demand for social workers that can act as care coordinators to help recipients connect their benefits across their care providers, communities, and homes.

As the healthcare landscape continues to change, social workers will be key players in advising and implementing improvements.

Read this post in its entirety at the Simmons School for Social Work. The oldest school of social work in the country, Simmons School of Social Work (SSW) was founded in 1904 as a joint venture with Harvard University. Today, SSW offers a rigorous, clinical social work curriculum that prepares students for direct practice with individuals, groups, and families. This post was authored by Chris Ingrao, the community manager for SocialWork@Simmons, the online MSW offered through the Simmons School of Social Work.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

Evidence-Based Health Coaching: Motivational Interviewing in Action is the first MI video training series especially designed for clinicians who serve individuals at risk of, or affected by, chronic diseases. Whether you are serving in a wellness, disease management, or care management program, or a primary or specialty care setting, hospital or community program, this series will help you build the practical MI knowledge and skills you need to support your patient health and address the behavioral factors that are responsible for over 85% of avoidable healthcare costs.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

The increased role of IT in the healthcare sector has led to the coining of a new phrase “health informatics,” which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks.

When transitions of care are poorly coordinated, both the patient and the healthcare organization suffer. Without proper education, timely follow-up and tools to self-manage, patient complications and readmissions increase significantly. Healthcare organizations need effective and scalable ways of engaging and empowering patients to take active roles in their health post-discharge.

A new infographic by Emmi Solutions examines the importance of patient engagement for care transitions.

Management of patient handoffs—between providers, from hospital to home or skilled nursing facility, or SNF to hospital—is a key factor in the delivery of value-based care. Poorly managed care transitions drive avoidable readmissions, ER use, medication errors and healthcare spend.

In 2015 Healthcare Benchmarks: Care Transitions Management, HIN’s fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Given the potential for healthcare wearables to improve outcomes and reduce costs for patients with chronic conditions, healthcare organizations are examining what would motivate consumers to use these devices to track their health, according to a new infographic by iTriage.

The infographic examines why consumers are hesitant to use wearables and what might sway consumers to adopt their use.

From home sensors that track daily motion and sleep abnormalities to video visits via teleconferencing, Humana’s nine pilots of remote patient monitoring test technologies to keep the frail elderly at home as long as possible. When integrated with telephonic care management, remote monitoring has helped to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges.

Health risk stratificationfor example, grouping diabetics in a single physician practice or drilling down to an ACO’s subset of medication non-adherent diabetics with elevated HbA1csfollowed by risk-appropriate interventions can significantly enhance a healthcare organization’s clinical and financial outlook.

For 9.4 percent of respondents to HIN’s 2014 Health Risk Stratification Survey, risk stratification resulted in program ROI of between 3:1 and 4:1, while 6.3 said return on investment was greater than 5:1.

Stratification and targeted interventions also generated a healthy drop in healthcare cost, nursing home stays, ER utilization and time off work while boosting quality ratings, patient engagement levels and care plan adherence.

Survey respondents further quantified successes achieved from health risk stratification in their own words:

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement  data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry’s value-focused climate.

Eight million of the 40 million older adults in the United States have multiple chronic conditions and receive help with activities of daily living (ADLs), according to a new infographic by the GRACE Team Care (Geriatric Resources for Assessment and Care of Elders) program at Indiana University School of Medicine.

This 20 percent of the senior demographic comprises 40 percent of healthcare spending, and the per capita healthcare spending for these seniors is about double than for those without the need for help in ADL. Medicare hospitalization collective cost to the healthcare system is more than $140 billion.

The infographic illustrates how participation in the GRACE program has been proven to provide person-centered care, enhance quality of life, optimize health and functional status, and decrease excess healthcare use.

The desire to improve health outcomes for individuals with serious illness coupled with opportunities to generate additional revenue have prompted healthcare providers to step up chronic care management initiatives. The Centers for Medicare and Medicaid Services now reimburses physician practices for select chronic care management (CCM) services for Medicare beneficiaries, with more private payors likely to follow suit.

When the largest FQHC in the country set out to quantify the contributions of its multidisciplinary care team, it found the concept didn’t fit neatly into return on investment models.

So at budget time this year, leaders of AltaMed Health Services Corporation’s care coordination model for its highest risk patients identified seven performance metrics to present to its CFO, explained Shameka Coles, AltaMed’s associate vice president of medical management, during A Comprehensive Care Management Model: Care Coordination for Complex Patients, a May 2015 webinar now available for replay.

The evidence that ultimately secured funding for the care coordination project’s next phase included the model’s impact on specialty costs, emergency room visits, and HEDIS® measures, among other factors.

These were all areas examined early on, back in phase one, when the care coordination team set a number of strategic goals that aligned with the corporation’s five pillars: service, quality, people, community and finance.

Rolled out in four phases beginning in July 2014, the model is aimed at AltaMed’s dually eligible population Medicare-Medicaid beneficiaries with high utilization, multiple chronic conditions, and multiple functional and cognitive impairments, Ms. Coles explained.

Phase one of the project was devoted to understanding and engaging the duals population via telephonic and print outreach, then developing a care management model reflecting both Triple Aim and patient-centered medical home goals. (The 23-site multi-specialty physician organization in Southern California has earned Joint Commission primary care medical home designation.)

At the heart of the model is a multidisciplinary care team, which counts a care coordinator, clinic patient navigator and care transitions coach among its eleven roles. Patients are stratified as high, moderate or low risk and matched to risk-appropriate interventions.

“Each member is activated based on where the patient is at in the continuum of care,” noted Ms. Coles, who also reviewed team member roles and responsibilities and a host of complementary programs supporting care coordination during the May 2015 program sponsored by the Healthcare Intelligence Network.

In phase two, focused on development of end-to-end workflows, staff assessments and ratios, and team training, AltaMed hired an educator, fleshed out the patient navigator role, and examined integration of behavioral health and long-term services and supports (LTSS).

Phase three triggered a deeper dive into case manager caseloads and utilization patterns as well as several quality improvement activities.

Now in phase four, the goal of AltaMed’s care coordination model is to ensure it can reflect a financial impact. “We’ll look very closely at our per member per month cost and our inpatient metrics,” Ms. Coles concluded.

More than two-thirds of healthcare decision-makers consider analytics among one of their organization’s top three priorities, according to a new infographic by Vigyanix.

The infographic looks at the factors driving analytics and how big data analysis can benefit healthcare.

The world of digitally enabled care is exploding: the number of patients using telehealth services will rise to 7 million in 2018, according to IHS Technology; healthcare apps and ‘wearables’ are trending in technology circles and healthcare providers’ offices; and CMS’s new ‘Next Generation ACO’ model is expected to favor expanded telehealth coverage.

2015 Healthcare Benchmarks: Telehealth & Telemedicine delivers actionable new telehealth metrics on technologies, program components, successes and ROI from 115 healthcare organizations. This 60-page report, now in its fourth year, documents benchmarks on current and planned telehealth and telemedicine initiatives, with historical perspective from 2009 to present.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Advance care planning is extremely personal and very complex, leaving many patients to either opt out of making decisions at all or too uncomfortable to discuss them with their provider, according to Emmi Solutions.

A new by Emmi Solutions provides strategies for providers to engage patients in advance care planning.

In its September 2014 report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” the Institute of Medicine recommends the development of measurable, actionable, and evidence-based quality standards for clinician-patient communication and advance care planning to reflect the evolving population and health system needs. Poor prognoses, the loss of functional capabilities, and the need for advanced care planning are just some of the emotionally charged challenges of caring for individuals with advanced illness.

Download this FREE report for data on the top clinical targets of healthcare case managers; the top means of identifying and stratifying individuals for case management; and the most common locations of embedded or colocated case managers.